Age-Related Macular Degeneration GUIDELINES Pocket Guide

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The digital subscription version of the Age-Related Macular Degeneration GUIDELINES Pocket Guide contains all the same great information found in the physical pocket guide, and can be accessed on mobile devices and online:

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The Age-Related Macular Degeneration GUIDELINES Pocket Guide is based on the latest recommendations of the American Academy of Ophthalmology and was developed with their collaboration. This practical quick-reference tool contains detailed, graded recommendations for diagnosis and management of macular degeneration, fundoscopic images and tables summarizing classification and treatment modalities.

Spiral Bound

16 pages

80# Diamond Silk Cover with Satin Aqueous Coating

4.25″ x 7.25″

Key Points

Risk Factors

Definition with Funduscopic Images

Tables

Classification of AMD from the AREDS

Treatment Recommendations and Follow-up for AMD

Antioxidant Vitamin and Mineral Supplements used in the AREDS2

Summary of Results of Original AREDS for Developing Advanced AMD and Vision Loss

Detailed, graded recommendations for diagnosis and management including treatment modalities

The American Academy of Ophthalmology is the largest national membership association of Eye M.D.s. Eye M.D.s are ophthalmologists, medical and osteopathic doctors who provide comprehensive eye care, including medical, surgical and optical care. More than 90 percent of practicing U.S. Eye M.D.s are Academy members, and the Academy has more than 7,000 international members.

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Age-Related Macular Degeneration GUIDELINES Pocket Guide

Key Points

Table 1. Recommendation Grading

High-quality meta-analyses, systematic reviews of randomized controlled trials (RCTs), or RCTs with a very low risk of bias

I+

Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias

I-

Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias

II++

High-quality systematic reviews of case-control or cohort studiesHigh-quality case-control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal

II+

Well-conducted case-control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal

II-

Case-control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal

III

Nonanalytic studies (e.g., case reports, case series)

Evidence Ratings2

G - Good quality

Further research is very unlikely to change our confidence in the estimate of effect

M - Moderate quality

Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate

In - Insufficient quality

Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimateAny estimate of effect is very uncertain

Recommendation Ratings3

S - Strong recommendation

Used when the desirable effects of an intervention clearly outweigh the undesirable effects or clearly do not

D- Discretionary recommendation

Used when the trade-offs are less certain—either because of low-quality evidence or because evidence suggests that desirable and undesirable effects are closely balanced

1. To rate individual studies, a scale based on Scottish Intercollegiate Guideline Network (SIGN) is used.2. The body of evidence quality ratings is defined by Grading of Recommendations Assessment, Development and Evaluation (GRADE). GRADE is a systematic approach to grading the strength of the total body of evidence that is available to support recommendations on a specific clinical management issue.3. Key recommendations for care are defined by GRADE.

Although an estimated 80% of age-related macular degeneration (AMD) patients have non-neovascular or atrophic AMD, the neovascular form is responsible for nearly 90% of the severe central visual acuity loss associated with AMD.

The primary risk factors for the development of advanced AMD include increasing age, ethnicity, and genetic factors. Cigarette smoking is the main modifiable risk factor that has been consistently identified in numerous studies. Smoking cessation is strongly recommended when advising patients who have AMD or are at risk for AMD.

A meta-analysis of 10 studies found that the use of aspirin may not be associated with an increased risk of AMD. Therefore, patients who have been instructed by a physician to use aspirin should continue to use it as prescribed.

Antioxidant vitamin and mineral supplementation as per the original Age-Related Eye Disease Study (AREDS) and AREDS2 trials should be considered in patients with intermediate or advanced AMD. There is no evidence to support the use of these supplements for patients who have less than intermediate AMD.

Replacement of the beta-carotene from the original AREDS formulation with lutein/zeaxanthin in the AREDS2 supplements may decrease the risk of lung cancer in smokers.

In patients with neovascular AMD, early detection and prompt treatment improves the visual outcome. Treatment with AREDS2 supplements reduces the progression to advanced AMD in the fellow eye.

Intravitreal injection therapy using anti-vascular endothelial growth factor (VEGF) agents (e.g., aflibercept, bevacizumab, and ranibizumab) is the most effective way to manage neovascular AMD and represents the first line of treatment.

Etiology

Risk Factors

In light of all the available information on the subject of aspirin use and age-related macular degeneration (AMD), current recommendations are for those patients who have been instructed to use aspirin by a physician to continue their aspirin therapy as prescribed. (II++, G, S)

Routine genetic testing for risk alleles is not currently recommended for patients with AMD. (III, In, D)

a There are a number of classifications of AMD in the literature. The AMD Preferred Practice Pattern uses the AREDS classification and a more recent clinical classification to define the early and intermediate stages of AMD since current treatment recommendations are based on these classifications.

Care Process

The initial evaluation of a patient with signs and symptoms suggestive of AMD includes all features of the comprehensive adult medical eye evaluation, with particular attention to those aspects relevant to AMD. (II++, G, S)

A physical examination should include a comprehensive eye exam. (II++, G, S)

A physical examination should include stereoscopic biomicroscopic examination of the macula. (III, G, S)

Binocular slit-lamp biomicroscopy of the ocular fundus is often necessary to detect subtle clinical signs of CNV. (III, G, S)

Optical coherence tomography (OCT) is important in diagnosing and managing AMD, particularly with respect to determining the presence of subretinal fluid and in documenting the degree of retinal thickening. (III, G, S)

OCT also assists in evaluating the response of the retina and RPE to therapy by allowing structural changes to be followed accurately. (II+, G, S)

Intravenous fundus fluorescein angiography is helpful to assist in determining the cause of visual loss that is not explained by the clinical examination. (III, In, D)

If CNV is suspected on the basis of new symptoms or ocular findings, fluorescein angiography should be performed and interpreted expeditiously by an individual experienced in managing patients with neovascular AMD. (III, G, S)

If fluorescein angiography is performed, the physician must be aware of potential risks associated with this procedure. (II-, G, S)

Each angiographic facility should have a care plan in place for an emergency situation, as well as a clear protocol to minimize the risks and to manage complications. (III, G, S)

Color fundus photographs may be obtained when angiography is performed, because they are useful in finding landmarks, evaluating serous detachments of the neurosensory retina and RPE, and determining the etiology of blocked fluorescence. (III, G, D)

Fundus photographs may also be used as a baseline reference for selected patients with advanced non-neovascular AMD and for follow-up of treated patients. (III, G, D)

When ICG angiography is performed, the physician must be aware of potential risks associated with this procedure: severe medical complications, allergic reactions, and even death. (III, G, S)

Several other tests including fundus autofluorescence, microperimetry and adaptive optics have been used for evaluation of patients with AMD. However, their role in clinical practice is poorly defined at this time. (III, In, D)

Patients with early AMD and/or a family history of AMD should be encouraged to assess their own visual acuity using monocular vision testing (i.e., Amsler grid), and have scheduled dilated eye examinations for detecting the intermediate stage of AMD. (III, G, S)

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